RESUmo
O estudo de abordagem qualitaiva teve como objeivo compreender as relações sociais entre o Agente Comunitário de Saúde (ACS) e a equipe de Saúde da Fa -mília (SF), nesse senido, destaca-se a ar -iculação das ações e a interação entre trabalhadores. Foram realizadas 23 ob -servações paricipantes e 11 entrevistas semiestruturadas com uma equipe de SF em um município do interior de São Paulo, Brasil. Ideniicou-se que o ACS, como elo, desenvolve ações operacionais para agi -lizar o trabalho da equipe. Como laços de ligação, desempenham ações ariculadas ao trabalho da equipe, interagindo com os trabalhadores, construindo planos assis -tenciais em comum, aproximando equipe e comunidade, adequando ações de cuidado às necessidades das pessoas. Na práica co -municaiva, ao falarem de si, falam da pró -pria comunidade, pois é seu representante e porta-voz na equipe. Concluiu-se que o Agente Comunitário de Saúde pode ser um trabalhador estratégico se suas ações com -preenderem uma dimensão mais políica e social do trabalho em saúde.
dESCRitoRES
Auxiliares de Saúde Comunitária Atenção Primária à Saúde Programa Saúde da Família Equipe de assistência ao paciente
Cooperative interventions and the
interaction of Community Health
Agents within the Family Health team
*O
riginal
a
r
ticle
AbStRACt
This qualitaive study examines the so -cial relaionships between the Commu -nity Health Agents (CHAs) and the Family Health team (FH), highlighing cooperaive intervenions and interacions among workers. A total of 23 paricipant observa -ions and 11 semi-structured interviews were conducted with an FH team in a city in the interior of São Paulo, Brazil. The re -sults revealed that CHAs funcion as a link in the development of operaional acions to expedite teamwork. These profession -als, while creaing bonds, ariculate con -necions of teamwork and interact with other workers, developing common care plans and bringing the team and com -munity together, as well as adaping care intervenions to meet the real needs of people. In communicaion pracice, when talking about themselves they talk about the community itself because they are the community’s representaives and spokes -persons on the team. The conclusion is that the CHA may be a strategic worker if his/her acions include more poliical and social dimensions of work in healthcare.
dESCRiPtoRS Community Health Aides Primary Health Care Family Health Program Paient care team
RESUmEn
Estudio cualitaivo que objeivó compren -der las relaciones sociales entre el Agente Comunitario de Salud (ACS) y el equipo de Salud de la Familia (SF), destacando la ariculación de acciones e interacción entre trabajadores. Se realizaron 23 ob -servaciones paricipaivas y 11 entrevistas semiestructuradas con un equipo de SF en municipio del interior de São Paulo-Brasil. Se determinó que el ACS como eslabón desarrolla acciones operaivas para agilizar el trabajo del equipo. Como lazos de co -municación desempeñan acciones aricu -ladas al trabajo del equipo, interactuando con los trabajadores, determinando pla -nes asistenciales en común, aproximando equipo y comunidad, adecuando acciones de atención a necesidades de las personas. En la prácica comunicaiva, al hablar de sí, hablan de la propia comunidad, pues son sus representantes y portavoces en el equi -po. Se concluye en que el ACS puede ser un trabajador estratégico si sus acciones comprenden una dimensión más políica y social del trabajo en salud.
dESCRiPtoRES
Auxiliares de Salud Comunitaria Atención Primaria de Salud Programa de Salud Familiar Grupo de atención al paciente Karen namie Sakata1, Silvana martins mishima2
ArticulAção dAs Ações e interAção dos Agentes comunitários de sAúde nA equipe de sAúde dA FAmíliA
ArticulAción de Acciones e interAcción de los Agentes comunitArios de sAlud en el equipo de sAlud de lA FAmiliA
* extracted from the thesis “A inserção do Agente comunitário de saúde na equipe de saúde da Família”, university of são paulo at ribeirão preto, college of nursing, 2009. 1rn. msc, university of são paulo at ribeirão preto, college of nursing. specialist in teaching laboratory, research and extension at
the university of são paulo, school of nursing, collective Health nursing department. ribeirão preto, sp, Brazil. karen.namie.sakata@gmail.com 2rn.
intRodUCtion
A world crisis was triggered in the 1970s as a conse
-quence of reduced economic growth, with inancial, po
-liical and ideological implicaions. A new order known as the “globalizaion of the economy” and the hegemony of
the neoliberal proposal guiding economic policies was im
-plemented and relected in the social sphere. The health ield, in response to the crisis and the need to broaden the
possibiliies of care coverage to the less privileged, pro
-moted in 1978 the Internaional Conference on Primary Health Care, in which the Declaraion of Alma-Ata was
writen. As the main goal for all countries, it recommend
-ed that by 2000 all world ciizens would be able to achieve a level of health that permited them to have a socially and economically producive life. Such a goal became known as Health for All in 2000 and the Primary Health
Care (PHC) was seen as a strategy for its achievement(1).
About 30 years ater the Conference, the proposed goals and outcomes have yet to be fully
achieved and new challenges have been in
-troduced. Hence, a theoreical and pracical
review of PHC has been undertaken world
-wide to criically relect on the health needs and the development of people in order to produce a renewed concept of PHC. The
renewed PHC stands out with the estab
-lishment of essenial values, principles and elements, while equity and solidarity are aspects to be pursued. The renewed PHC
approach is intended to guide the trans
-formaion of health systems with a legal, insituional, and organizaional basis, and
human, inancial resources that are techno
-logically sustainable and appropriate to cul
-tural, social, poliical and economic aspects
of each country and region(2-3).
The Brazilian Uniied Health System (SUS) was created in 1988 based on the Sanitary Reform movement. The SUS, based on PHC, is a strong legal and poliical structure
whose doctrinal and organizaional principles are ground
-ed in integrality, universality, equity, problem-solving ca
-pacity, decentralizaion and social control and paricipa
-ion. However, it also faces challenges and limitaions for its pracice to consitute efecive implementaion in PHC in Brazil.
Theoreical Support
There were experiences and proposals in Brazil regard
-ing the implementaion and strengthen-ing of the SUS and
PHC. The Family Health Strategy (FHS) is currently consid
-ered a priority for the reorganizaion of healthcare in Bra
-zil. Care within the FHS is provided by a mulidisciplinary team composed of one nurse, one nursing technician or auxiliary, one physician and up to 12 Community Health
Agents (CHA)(4)
CHAs are workers who emerged from a naional exper
-iment in the state of Ceará, Brazil in 1987 and are current
-ly included in the FHS team. Since Ju-ly 2002, it has been a
profession characterized by the exercise of aciviies relat
-ed to the prevenion of diseases and health promoion(5).
The main acivity of CHAs includes home visits, followed
by health educaion concerning guidance on hygiene; im
-munizaion schedules; the correct use of medicaion; and
care provided to newborns, pregnant women and puer
-peral women(6).
A technical dimension and a poliical dimension are discussed concerning the work of these agents. The irst refers to care provided to individuals and families, to the prevenion of diseases, and the monitoring of groups or speciic groups. The second encompasses a proposiion
to organize the community to transform its health condi
-ions. CHAs are a more ethical-communitarian interpre
-taion as an element promoing the organizaion of the community toward ciizenship from a perspecive of social
transformaion. However, these two dimen
-sions are not yet synthesized in the pracice of CHAs; one or another is more frequently
employed, depending on the context (7).
Despite diiculies, CHAs are workers with unique characterisics because they are
in constant contact with people in the com
-munity and with workers from the health staf. It contributes to changing the health model since it can facilitate communicaion,
exchange of informaion, and the establish
-ment of trust ies between these two actors. It is important to note that CHAs should not merely act as informants but be acive agents in this process(7-10).
Represening the knowledge and prac
-ice of CHAs as a ‘link’ (seen as part of a
chain and an industrialized, rigid, cold piece closed in it
-self) and as a ‘bond’(understood as a noion of mobility, a ribbon ie, a cratwork that can be adjusted according to
the need), to be a link of chain only when conveys infor
-maion or as a ribbon ie when interacion and dialogue is established among subjects and their diferent types of knowledge, bringing together the community and the
staf through human relaions(11).
Posiive aspects and limitaions emerge in the work of CHAs when they become part of the health staf. If, on one hand, the opportunity to acquire new knowledge, easy access to professionals and health services, feelings
of appreciaion, belonging, self-esteem, presige and ac
-knowledgement are posiive characterisics, on the other hand, dissaisfacion with qualiicaions and inappropriate training, diiculty interacing and communicaing with the
team’s other professionals, frustraion, uncertainty, help
-lessness, and a feeling of worthlessness are posed as limi
-taions(7, 9,12-13). Considering that a team is a structure in a
A technical dimension and a political dimension are discussed concerning
the work of these agents.(...) However, these two dimensions are not yet synthesized
in the practice of cHAs; one or another
is more frequently employed, depending
process of constant disrupion and re-structuring, not on
-ly a group of professionals working together(14), this study
sought to understand the social relaions established be
-tween CHAs and the FHS team based on the work process of the health staf, highlighing the aspects of joint acion and interacion among workers.
There are diferences between a team group and team
integraion. Both have two dimensions: one of acions
and tasks and one of agents. There is in the team group,
as explicit in its own name, only the grouping of acions
and agents, while in a team integraion, acions are con
-nected and agents are in interacion(15).
Joint acions involve instances in which agents put into evidence the connecions exising among acions and the various types of technical knowledge. Such acions require agents to have a conscious and acive aitude, showing connecions among the technical intervenions of the various professionals and jointly construcing a common intervenion project based on negoiaion, sharing and
solidarity. Interacion depends on linguisic communica
-ion that becomes familiar, that is, communicaion, mutu
-al comprehension and understanding are required among
the subjects so that interacion is established(16).
Considering team as a structure in constant disar
-ray and in a constant restructuring process, this study sought to understand the social relaionships established
between CHAs and the FHS team based on health team
-work, highlighing the aspects of joint acions and interac
-ion among workers.
mEtHod
The seing of this qualitaive study was a health unit in a city in the interior of São Paulo, Brazil. The study’s
subjects included all members of the FHS team and its re
-specive Oral Health team: four CHAs, one dental oice assistance, two nursing auxiliaries, one dental surgeon, one nurse, and one physician and the manager of the health unit, totaling 11 health workers.
A total of 23 paricipant observaions and 11
semi-structured interviews were conducted. There was a spe
-ciic script to guide the paricipant observaion together
with the CHAs and another for the semi-structured inter
-views, individually held with each worker of the FHS team. The script for the paricipant observaion contained data to contextualize the observaion and four main aspects to be observed: those related to the paricipants, to the
development of acions, to the complementarity and in
-terdependency of acions, and interacion and commu
-nicaion among health workers. The script for the semi-structured interviews addressed the characterizaion of the interview, of the interviewee, and of the interview
per se with eight guiding quesions. Its inal version was
reached only ater observaions, which indicated the most perinent and relevant quesions for the study. The obser
vaions were recorded in a ield diary and interviews were recorded and transcribed verbaim. Observaions were
held from March to June 2008 (four months) and the inter
-views were held from July to August 2008 (two months).
The empirical material was themaically analyzed(17).
Qualitaive analysis was conducted to idenify the pres
-ence of meaningful elements to construct core meanings.
Even though, the stages of exploraion of material, treat
-ment of results, and interpretaion follow a certain count of frequency of core meanings to develop the themes, they were mainly based on the search for elements that
addressed the study’s objecive or were able to make un
-expected facts emerge from the empirical data. The core
meanings were grouped into the following themes: the his
-tory of the health unit and the FHS team workers, the team
work process, and the CHAs in the FHS team from the per
-specive of joint acions and the interacion of subjects. The later was more exploited in the development of this study. Ethical issues were complied with in accordance with
Resoluion 196, Naional Council of Health(18). The study
was approved by the Ethics Research Commitee at the
University of São Paulo at Ribeirão Preto, College of Nurs
-ing (protocol 0764/2007), and authorized by the City Health Department. All the paricipants consented to it.
RESULtS
The Community Health Agent as a link
The link nature of CHAs’ work is reinforced when they
perform essenially operaional tasks aiming to expedite
teamwork and the health unit’s funcioning. These acivi
-ies are related to the work’s technical and operaional aspects such as delivering referrals or messages from the heath unit to people without connecing these tasks to more integral care acions:
uh, like when we have to deliver an urgent referral, or an id card, call a patient for an appointment with the doctor right away, give a message (…) (silence). Well, this is not exactly our job, but we do it willingly (interview 4, cHA).
Acions connected only at the aciviies’ technical and operaional level may convey the idea that the work of CHAs is restricted to making appointments or delivering messages:
since it is a bit far away, they [users] want us to do it for them. they don’t want to go to the unit. (…) i mean, make appointments, check things for them, send them messag-es, you know? (interview 4, cHA).
A good job is when you dedicate yourself and do your best to solve someone’s problem. Because it doesn’t help if you go there and transmit information, you just transmit infor-mation and that’s it. i guess you should also seek a solu-tion (interview 3, cHA).
they [cHAs] go there, and when the campaign starts they report Look, the campaign to prevent the lu, then ... some-times, they bring the immunization card for us to see… to check whether the patient is going to get the shot, whether he needs it or not, you know? And we note the day of the vaccination campaign, the day of the home visit, it’s the agent who goes there, informs the family, who then waits for our visit (interview 9, health worker).
The Community Health Agent as a bond
CHAs as a bond seem to perform acions linked to the
health staf, interacing with other workers in order to en
-able integral care for people and individuals in the com
-munity. This bond dimension between people and health
workers occurs due to the fact that CHAs know the indi
-viduals, their families, their homes, and seek to idenify their needs. Addiionally, CHAs live and work in the context
of this community, go to people’s houses and have the op
-portunity to idenify needs, which normally would not be recognized in the context of the health unit. Such needs go beyond biological disease and can be intra-family conlicts,
domesic violence, need for food, sexual abuse, child ne
-glect, or mistreatment of elderly individuals, among oth
-ers. These situaions are extremely complex and imply that there is a great distance for CHAs to reach an opportunity to idenify them based on the construcion of bonds with the family and longitudinality of care:
We are a link between the community and the profession-als there (…). i guess it’s great. (…) Because the profes-sionals know how the patients act in their homes, with their families, with their children… (interview 2, cHA)
uh, i guess we cooperate a lot, you know, with the entire team, if it is not the entire team, if there’s not the agent to care, you see? Because each one sees from a different perspective; our perspective shows what is real outside the unit, you see? What we show them is real, and they know that, because they don’t know what happens outside (silence) (interview 5, cHA).
The other members of the FHS team spend more ime inside the unit, hence, possibiliies to come into contact with people in a more favorable and less insituionalized environment, such as their home, are limited. The CHAs, in turn, are those who have more reliable informaion concerning the social inclusion of people in their home environment and in the community, factors that inluence the health-disease-care coninuum:
the community agent is that element, you see, that person who brings information we aren’t able to get here inside the health unit (...). the agent goes to the patient’s house; we see whether the problem is lack of food, or lack of hy-giene…he sees a lot of things we have no means to know
Such work seems to provide a certain sense of security and peace of mind to the other workers because they are able to know people beter and the territory in which they are working through the work of CHAs.
they are our arms and eyes. (...) it gives us some peace of mind, because we work in a place where we recognize, we know what is happening. it’s a known territory (interview 6, health worker).
The work of CHAs as a ‘bond’ means they are also part of the construcion of the care plan developed by the staf. Their work seems to occur from the perspecive of the joint construcion of a common care project:
sometimes, there’s a person who has a very severe asth-ma, goes to the doctor, uses an inhaler all the time and it doesn’t go away. But sometimes, they don’t know there’s a cat in the house… there’re lots of rugs, curtains, dog. (…) then, we usually say ‘no, but there, oh , there’re damp walls, there’s this and that (interview 3, cHA).
then, i came into contact with the community agent; she informed me of everything, she said “this patient did physi-cal therapy many years ago in such a place. And this and that…”she told me everything how she did it. I got the ile, saw the last two visits of [name of the team’s nurse], the records, everything. so, we already knew everything, you know? i found it interesting. she [cHA] knew everything that was happening with that patient. so, we went to her house, i went to see her, she regularly used oxygen ther-apy, you know? regularly, uh… i explained exactly what we were doing there. Why we were there. so, it was very nice, because we are already committed to take some ac-tion, you know? When we went back, i mentioned to her
Oh, let’s talk about this with the doctor who comes back on
Monday from vacation so, she takes notes, you know?
re-cords everything. When we got there, we also reported the case to the auxiliary of that specialty. so, like, we end up in-forming everybody, you know? (interview 6, health worker).
In the same way CHAs are asked by the team to con
-tribute to a care plan, they also seek other workers when they are faced with needs of the populaion that they are not able to meet by themselves:
sometimes, the problems they [cHAs] are not able to solve. (...) He says like “let’s go there because you can better convince him. i’ve already invited him, i’m talking to him, but it’s not working” (interview 9, health worker).
In addiion to the opportuniies that are designed for the exchange of informaion among health workers, such
as team meeings, communicaion also takes place out
-side these more formal places, i.e. in the corridors, de
-pending on the decision-making of workers in the face of situaions they encounter.
For her [the physician], it’s more… she sometimes comes in the middle of the meeting, sometimes, at the end. (…) sometimes, they [nursing auxiliaries] are doing something else, sometimes they arrive in the middle (…). they [oral Health team] are doing some procedure, something, and can’t participate (interview 5, cHA).
it was late in the afternoon, one community agent was waiting a nurse near by. she seemed to want to talk about something while the nurse was assisting a mother with her child. For a moment, the nurse looked at the agent, who started to tell about the case of a user who had a urinary infection but didn’t want to take the medication. the nurse, while talking to the agent, continued to provide care and left the room in a hurry with the mother and the child. she kept talking to the agent while she followed the doctor and talked about the case. the nurse was walking ahead and seemed to give little importance to what the agent was saying. the agent was following the nurse and talking to her in the corridor. At the end, the nurse only told the agent she had already talked to the user. the agent said ok and left but seemed not to be very satisied with the talk she just had with the nurse (observation 5).
The fact that CHAs can access the staf and establish
communicaion in a dialogical relaion can help them fa
-cilitate access to the health services for people. If on the one hand, they take the workers to the people’s houses, on the other hand, when people go to the unit they also irst look for the agents, because they acknowledge they are able to meet their needs or organize the demand for the other health workers:
they (health service users) seek the community agent, stop by to see what can be solved, (…) because they know that if it is necessary, i go with the nurse, i go with the nurse; if there is a need to go with the physician, i sched-ule to go with the physician (interview 3, cHA).
When the community health agents talk about themselves, they talk about the people in the community.
Seeing CHAs as the representaives of the community in the health unit implies considering that the elements present in their relaionship and the health staf, whether in joint acions or interacion, can also indicate elements present in the relaionships between workers and users
in the intercessory spaces of care. The following observa
-ions exemplify this:
during a meeting between the cHAs and one worker with a college degree, the latter talked most of the time while the cHAs kept silent. one cHA tried to establish com-munication with the worker twice, asking questions about the subjects they were discussing, but the worker would provide brief explanations not making sure the cHA had understood it and without giving her a chance to express herself (observation 5).
one cHA was waiting to go make home visits with a work-er with a college degree, while the lattwork-er was rapidly as-sisting one user who had gone to conirm the result of an
exam. there were times the user seemed to want to ask a question but when she would talk, the worker would inter-rupt her, mechanically reading the exam’s results. then, after many attempts and much insistence, the user asked a question at the end of the consultation, whether the re-sult was related to a change observed in another blood test she had taken months ago. the answer she got from the health worker was It has nothing to do with it… the
important thing is that you keep following my recommen
-dations (observation 4).
Neither the CHAs from the irst observaion nor the user from the second observaion were able to efecively paricipate in the conversaion, establishing a dialogue
with the health worker. These two observaions are simi
-lar in the way the agents and users are trying to put them
-selves before the staf as acive agents co-responsible for the plans of implementaion and development of care.
CHAs are part of the communiies they monitor; they live in the covered area and oten share the same needs of the individuals from the community and experience the same problems in the neighborhood:
one cHA was saying that her three-year old child expe-rienced intense vomiting and she took him to the emer-gency department; he was already showing signs of dehy-dration. she said that the physician on duty was negligent and sent them home only with medication for pain. When she asked about the need for offering saline solution, the physician answered aggressively in a loud voice Do
you know how many years you have to study to become a
physician? (observation 22).
This observaion reveals aspects related to accessibil
-ity and care delivery that do not meet the needs of the CHA who experiences situaions that are similar to those experienced by health service users.
diSCUSSion
In the link dimension, the CHAs and other workers
are not interacing among them because the communica
-ion required to construct a common care project is not put into pracice. When it is, it occurs only as a means to opimize the aciviies’ techniques and operaion. CHAs
should not have the mere funcion of transmiing mes
-sages; they need to be involved with an aitude of being co-responsible for the care provided. The health staf and managers need to take care that CHAs do not work from
the perspecive of a team group, merely reproducing me
-chanical pracices without the possibility of being agents that transform the care provided to people. Strategies are needed to ensure the inclusion of CHAs in the FHS team
focused on interacion and cooperaion, enabling the po
-tenial to change the health model and care pracices.
It seems that, when acing as a bond, CHAs estab
-lish communicaion free of constraints with other health
developed together, because there is a mutual search among them in order to obtain informaion or ask for help to improve the care provided to individuals and families.
It seems that interacion between CHAs and other health workers, when the iniial acion in this dimension, happens in an instance of communicaion intrinsic to the
teamwork that is revealed in the development of a com
-mon objecive(20). In this case, the common objecive is
the care provided to the individual, which is considered together with other workers and CHAs.
When communicaion is intrinsic to the teamwork, people see CHAs as facilitators of access. In this respect,
one can say that agents acing as bonds, included in the
FHS team as a worker, can contribute to care delivery as being integral and meeing the needs of individuals and families based on a core competence and responsibility, even if these are yet poorly deined. By core competence
and responsibility, we mean a set of diferent types of
knowledge and responsibiliies speciic to each profes
-sion or specialty.(19) By itself, the core competence of each
professional is not able to meet the complexity of health needs presented by individuals and families.
Each worker in the FHS has its speciic core competence and all of them are important to the process of construcing
integral care. For this reason, teamwork from the perspec
-ive of integraion is not an easy or rapidly completed task, nor a responsibility of a single professional(21).
In the process of division of labor in health, the vari
-ous specialized jobs are related and complementary topics, which when combined, extend the possibiliies to recognize
and meet the needs of people(15).
The core competencies and responsibiliies of CHAs may be taking shape in a historical and social process of this profession, in acions of construcing bonds with the
community and with other workers, adaping the produc
-ion of health care to the needs of people, as connecing
links.
The manner of CHAs’ behavior is included and how they include themselves in the FHS team inluences the way they are seen and accepted by the community. If, on
the one hand, they mean easier access to the health ser
-vice when they are integrated into the FHS team, on the
other hand, they may be seen as mere deliverers of mes
-sages and people who make appointments only when they are individuals grouped with a team. If in the irst case,
they reinforce the characterisic of connecing bonds, in
the second case they are rigid links forcing a relaionship without dialogue and without a more intense use of light technologies between communiies and workers.
It also encourages us to relect that diiculies of in
-teracion among health workers and CHAs may represent communicaion diiculies with the community itself, because CHAs are the representaives of the community within health services.
It is important to take care that language in the team is not used as a form of power and a means to exclude
workers, such as when using codes or technical terms with
those who do not share the same technical skills, hinder
-ing mutual comprehension(22).
There seems to be a certain fear on the part of CHAs in quesioning and posiioning themselves in the face of situaions or workers with a college degree. It may be due
to the presence of power relaionships, a hierarchy or so
-cial inequaliies. At the same ime, it reveals the diiculty FHS workers have dealing with new forms of care, with
the presence of new workers (CHAs), and new actors (us
-ers) with a desire to be more acive in their work and care processes.
For conlicts, dissaisfacion and diiculies should be made public and shared by the team with the intent to jointly improve work. For this, an opportunity to dialogue needs to be created, reinforced and valued in the rouine of teamwork. These opportuniies need to give a voice and expression to CHAs within the team, because they are the presence and the voice of a populaion that sill has its rights repressed, including rights to health and ciizenship.
The team’s health workers need to pay atenion to the various manners in which CHAs establish communicaion with the team in order to interact and expose people’s needs. Ater all, they are members of the community and their proximity to it make them a spokesperson within the team in the health unit.
When CHAs talk about themselves while commu
-nicaing with other workers, they are also talking about the community. When they talk about their own health needs, they are exposing the needs of the populaion they care for.
ConCLUSion
When CHAs work with the ‘bond’ characterisic, they seem to perform joint acions in terms of health teamwork
and when they interact with other workers, they help con
-struct common care plans that can enable integral care to be delivered to individuals and families in the community. As links, CHAs develop aciviies that are essenially op
-eraional: the individuals do not interact among them and
acions are not connected. The acions and aciviies per
-formed by CHAs someimes assume a coniguraion of in
-tegraion and other imes one of being part of the group. It leads us to conclude that the way agents are inserted and the way they insert themselves into the FHS team is
dynamic, because the team itself has a dynamic that is in
-herent to teamwork itself, with relaionships of hierarchy and subordinaion, diferent and unequal work, common care projects, interdependent and complementary work.
voice of the community itself, they can be strategic work
-ers. If their acions comprehend a more poliical and com
-munitarian dimension, then teamwork may be inluenced by noise that allows workers to think criically about their
work in health. However, if the work of CHAs is only cap
-tured by the technical dimension of the biomedical mod
-el, their acions will not have the potenial required to implement the desired changes in care pracices.
Intercessory spaces among the health workers them
-selves need to be created and strengthened so that the FHS work becomes more pleasant for health workers and more welcoming for individuals. These spaces, in which
being available for the knowledge or the lack of knowl
-edge of another, can conform new ways of producing care and conform the worker him or herself. These spaces are able to give more power to the voice and expression of CHAs in the communicaive acion with the staf.
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